On May 30, Sarah Murnaghan celebrated her 100th day in Children's Hospital of Philadelphia with her father, Fran, and mother, Janet. / Murnaghan family via AP

by Liz Szabo, USA TODAY

by Liz Szabo, USA TODAY

The second lung transplant given to a 10-year-old Pennsylvania girl raises new questions about how to make the best use of a precious resource, ethicists say.

Janet Murnaghan announced Friday that her daughter, Sarah, had received a second set of lungs after the first failed within hours of her June 12 transplant at Children's Hospital of Philadelphia. Murnaghan said Sarah, who has a life-threatening lung disease called cystic fibrosis, received the new lungs three days later.

Sarah's case was controversial, because her parents sued to get her onto the transplant list for an adult set of lungs. Typically, children are considered only for child-size lungs.

Although patients with cystic fibrosis now commonly live to age 40, Sarah wasn't expected to live more than a few weeks without a lung transplant. Although about 90% of lung transplant patients are alive after one year, the average survival for patients of any age after a lung transplant is only six years, says David Cornfield, chief of pulmonary and critical care medicine at Lucile Packard Children's Hospital at Stanford.

"Sadly, she faces very long odds of surviving," says Arthur Caplan, head of the division of bioethics at NYU Langone Medical Center in New York City.

"She apparently got low-quality organs to try and keep her alive to 'bridge' her to another transplant," Caplan says.

"Did it make sense to give her a second set of lungs in a pretty close-to-experimental procedure? She surely needed them, but given her medical situation, should she have been on the adult list in the first place?"

Even the idea of getting a second organ transplant is controversial.

"If the goal is to save lives with scarce lungs, should retransplants ever be done following an initial acute failure of a first set?" Caplan asks. "I would say no, if others could have used organs who had not had a first shot. That is a tough position, but lung transplants are rare, and not yet on a par with kidney or liver transplants."

Yet Cornfield says transplant surgeons feel they have a duty to help their patients survive.

"When physicians take on the responsibility for an individual patient, they will continue to advocate powerfully and unremittingly for the patient who is before them," Cornfield says.

"A physician caring for a patient with a failed lung transplant will do their utmost to ensure that patient has the best chance of survival, including if that means procuring another set of organs."

A second transplant has the best chance of success if performed within a short time after the first transplant, before scar tissue has a chance to perform, Cornfield says.

Murnaghan says Sarah is now taking some breaths on her own, although she continues to breathe mostly with the help of a ventilator. Over the weekend, Murnaghan posted pictures on Facebook of her daughter smiling weakly.

Sarah is scheduled for additional surgery to repair her diaphragm, which was damaged during the operation, her mother says.

"Sarah is doing well, alert, improving inch by inch," Murnaghan posted on her Facebook page this weekend. She added that she hopes Sarah's "surgery will bring us closer to successful extubation," in which doctors remove her breathing tube.

A previous attempt to remove Sarah from her breathing tube was unsuccessful, Murnaghan says. That has made Sarah much more anxious, her mother writes: "Ever since the unsuccessful extubation she has struggled with fears that she will suffocate and stop breathing."

Pediatrician G. Kevin Donovan, director of the Edmund D. Pellegrino Center for Clinical Bioethics at Georgetown University Medical Center, says it's always difficult to decide how to allocate organs, because it means denying someone a chance at life.

But the best way to make those decisions "is probably not to involve the courts," Donovan says. "The courts will have the same sympathy that we all would, but not the same medical information" as doctors at the bedside.

"It really is a very difficult case," he says. "And difficult cases make good publicity, but bad precedents."

The failure of the first transplant is not uncommon. A 2005 University of Pennsylvania study found nearly 12% of lung transplants experienced what's called primary graft failure, where the organ almost immediately begins to fail.

Donovan notes that transplants can fail for many reasons. The recipient's immune system may reject the foreign tissue. The recipient's blood vessels also may not match those of the donor. A clot also can block the blood supply, causing tissue to die from lack of oxygen, Donovan says.

Of 5,081 lung transplants performed from 2010 to 2012, there were only seven retransplants within a week of the initial operation, according to the United Network for Organ Sharing (UNOS), the private non-profit group contracted by the government to manage the transplant list.

According to UNOS, a graft failure does not automatically propel someone to the top of a waiting list, but it does affect the score, which is used to prioritize patients for the next available organ. Sarah was regarded as an adult, given a score and that score would need to have been at the top of the list for her specific tissue and blood type to be eligible for the next set of lungs.

In June, the Organ Procurement and Transplantation Network, which is overseen by UNOS, resisted making rule changes for children younger than 12 seeking lung transplants, but it created a special appeal and review system to hear such cases.

The meeting was prompted by the cases of Murnaghan and 11-year-old Javier Acosta of New York City that saw federal Judge Michael Baylson rule they should be eligible for adult lungs after U.S. Health and Human Services Secretary Kathleen Sebelius declined to intervene in such cases. Both children have end-stage cystic fibrosis, and Javier's brother died two years ago while on the waiting list.

Their families had challenged existing transplant policy that made children under 12 wait for pediatric lungs to become available or be offered lungs donated by adults after adolescents and adults on the waiting list had been considered.

The network said the new special review option will expire on July 1, 2014, unless the full board of directors votes to keep it in place.

In reviewing its policies, Donovan says the organ network should look carefully at the quality of the science. For example, he wonders, "what was the quality of the evidence that caused them to restrict lungs to children over 12 in the first place?"

Currently 1,663 people in the U.S. are seeking a lung transplant. Twelve are age 6 to 10.

"It seems cruel sometimes to not just give everyone who needs one an organ," Donovan says.

"And it is cruel, because there just aren't enough organs to go around."